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Hi, I am Dr. Mark Studin, and today we’re going to be discussing ranges of motion, hyper hypo, hyper versus hypomobility, and is it a valid indicator for future care. But first, I’d like to thank Cairo secure for the opportunity for allowing me to share this information with you. We’re gonna go right to the slides.
Now. When we look at the. of ranges of motion. That’s always one of the two main go-tos that the carriers look at to determine for the necessity for future care. And is it really fair? Is it accurate? Is it inaccurate? By the way, the other one is usually muscle testing, which is gonna be for a whole different topic.
And a whole different timeframe. Now, a little bit of housekeeping. I’m still a little bit of a computer nerd. I’ve got four screens in front of me. I’m gonna be reading off a screen right here today. So when you see this side of my face, that’s what I’m looking at the screen now. When we look at range of motion, it’s the chiropractic go-to it’s validation for initial care or extended care, and we use global ranges of.
Is it 45 degrees inflection? Is it 25 an extension lateral bending? We look at all of these different things in our initial evaluation and our reevaluations to determine if our care is working. So the question is, , is it fair and is it valid? And are there other things that you can do? But first, let’s look at Demonstr ability of ranges of motion.
Demonstrable means show and tell. So there is three things that we look at. One is instrumentation or just range of motion. It can be visual or instrumentation. Number two is George’s line. When you are measuring the stability of the spine, looking at one type of range of motion or ligament, this integrity and the other is x-ray, digitizing, all of those determine the ability of motion and the ligaments that hold that, those segments together, which is the purpose of the range of motion test.
Now, when we look at the first, we look at George’s line and we look at this. We see here on the. That if you look down L 5, 4, 3, 2, 1 in the back, the bones all line up. But now there’s a step off cause there’s a spy here with a spondylolysis that’s a step off. It doesn’t line up. So therefore we know that there’s a ligament, this injury, and we expect abberant range of motion, where if we look at the lines here, anterior, posterior they all line up and it’s valid in a healthy Georgia.
The next thing we look at is range of motion with a two piece inclinometer. Now, many of you eyeball it. That is not a clinically valid test to report degrees. In other words, it’s 20 over 45. I eyeballed it. That’s impermissible according to the AMA guise evaluation permit impairment Fifth. Page 400, and if you use the sixth edition, it refers back to the fifth edition.
For range of motion guidelines. If you’re going to report a valid number, you must use a two piece inclinometer. You must. You must. It could be analog or it could be digital. It could be a cheap J mar that you get on eBay for, a couple of hundred bucks. Or it could be a fancy one connected to a computer, connected to muscle spasticity and surface range of motion, and all this stuff that costs you 10, 12,000.
It doesn’t matter. It’s gotta be a two piece inclinometer, and that’s directly from the AMA Guides. Now, goniometers are only permissible for extremities and our throat protractors are only permissible to be used as a door stop in your office because they’re thoroughly not acceptable. So remember that range of motion, two piece inclinometer, and that’s right from the AMA Guides.
Now, when we look at global range of. and you’re seeing too little motion. What does that represent? Too little motion you’re looking at global from c1, usually to t1. It usually represents muscle spasticity. In some instances it can represent meniscal entrapment. We’ll talk about that later on with secondary muscle spasms in the area, which usually happen as a.
Of the nociceptors in the facets. We discussed this in a different seminar or the receptor is firing Aly. That’s what causes the muscle spasticity in the surrounding area, and the majority of the muscle spasticity is to try to create homeostasis mechanically or take a bone off. or take whatever you need to do, move things around shy away from the herniation, whatever the body needs to do in an antalgic posture.
Those are the different issues and reasons you could have muscle spasticity, lots of them. So the question is a global range of motion an act an a, a fair and accurate arbiter of the condition of the spine when you’re looking at too little? Is that an accurate arbiter of your treatment? And when range of motion comes back to normal globally, are you then supposed to be done with your care?
The carriers say yes because it’s, this entire process is skewed towards them. The question is, what is global range of motion? Let’s look at this example. On the left, you’re gonna see same person left and right, but look at this perfectly 45 degree normal flexion at c5. And six, there’s a fused vertebra at c5, and six, it’s fused.
How the heck can you have normal range of motion? with a fused motor unit. How can you do that? Let’s look at it. If we look at the sample that I created and I put lines and angles, and the angles aren’t accurate, by the way, it’s put there for academic purposes. But let’s look at it here. C1. C2.
Between C2 and three, you’ve got six degree angle between these six degrees of motion between. , these two vertebra in a motor unit that folks is normal, but C3 and four, I have 16 degrees. That’s abnormal. It’s too much. Then I’ve got C4 and five is 14 degrees. That’s abnormal. Then I’ve got C5 and six because it’s fused in the front.
It’s rocking backwards. It’s minus five degrees. That too is abnormal. But when I go to C6 seven, that’s 14 degrees. That’s abnormal. It’s too. But when you add all five motor units, it equals 45 degrees, but yet four out of the five. 1, 2, 3, 4 are pathological. Now, what are they pathological for? They’re pathological for biomechanics.
What is causing that biomechanical pathology? We know at C 56 you’ve got. But what’s causing the other four to be abnormal? The other three. I’m sorry to be abnormal. It’s easy. The answer is connective tissue pathology. They’re moving too much. They’ve gone beyond their para physiological limit.
Now, what’s metaphysiology limit? I put my hand up. I gotta bring it back. I can’t go anymore. I’m stuck. That’s the biophysiological limit. If I go more. I’m gonna break something or I’m gonna tear the ligaments. In this scenario, in the spine, you are tearing the ligaments in the spine and you have to determine what ligaments are being torn and where that’s connective tissue pathology.
And that’s a big issue. It’s a huge issue because that will always, and this is an Absolut. Always lead to future degenerative problems. Arthropathies not arthritis. That’s an inflammation of the joint. An arthropathy, a pathology of the joint. Now, how do I know that? Because Julius Wolf in 1859 coined.
Slaw, and that’s what Arthropathies is. That’s a degenerative process, and with a pressure on that vertebra, you’re going to have remodeling of the bone. Not sometimes, but every time in the human body. Non-negotiable. It’s a law. So therefore we know when these bones are aberrantly positioned, they’re going to put Arine pressure and through the, which I’m not gonna explain today, the mechanism through the Paso Electric.
you’re going to have Ionic exchange. It’s gonna suck calcium just like you see over here. And then it’s Go Wolf’s law. The bone’s gonna remodel. And that’s just the mechanism behind how it works, which plays heavily. Into how the chiropractic lesion works and the sequelae in our formative years. We call that subluxation degeneration.
Now, I had a nose to nose argument with a professor in in one of the chiropractic colleges where I teach in the University of Bridgeport School of Chiropractic. That’s one of the three institutions I teach. I’m I’m an adjunct professor at, and we had a nose to nose argument that’s all theoretical mumbo, jumbo subluxation stuff.
Show me the evidence. Guess what? Wolf’s law, it’s been in the evidence forever. And if you don’t like the word subluxation, use the word biomechanical. Pathology. I don’t really care. It’s the exact same. Don’t get lost in your philosophical belief or disbelief. Look at the science. It’s all there. All the evidence is in the literature and it’s been known for since 1859.
It’s been around for a long time now. When we look at perhaps the bone being aberly positioned, causing range of motion issues, we need to look at meniscal entrapment. And we discussed this a few months back when we talked about the mechanism. And by the way if you wanna learn more about this in a very detailed letter@teachdoctors.com, take primary spine care 12, 13 or 14.
We spend hours going through this stuff, but watch, there is normally placed a menis as a spacer between the facets when that menis comes out of. As you see here, it be, it folds, and this is all based upon the evidence in the literature. The facets approximate, just like symbols. The facets approximate that, by the way, folks, is where your bone or nerve is that chiropractors treat.
Right here, that’s your bone on nerve and it affects the nociceptors. It also affects the meca receptors. In the joint capsule you have bassian corpus, which are your crimp receptors, your re refining corpus, which are your stretch receptors, and you’ve got more nociceptors in the region all feeding into the lateral horn.
Up the spinal thalamic tract through the periaqueductal gray area hitting the thalmus it ping pongs cetra distribution center. It hits the prefrontal cortex, the anterior ular cortex, the motor cortex, the sensory cortex, the hypothalamus in a bunch of other areas, and all ping pongs are out until the motor cortex overrides that.
For muscles only, then it goes ether back down the through the thalamus, through the spinal thr, and then disparate areas, meaning you might have a problem in your lumbar, but your cervical and thoracic are going to spasm in different areas to create homeostasis, biomechanically, and watch to put some curves in there to create homeostatic plum, which is the least amount of energy used.
I’m not gonna explain any more of that right now, but what occurs. When that joint buckles, the inferior joint rides up just as explains here on the superior joint and it buckles. So therefore, you are getting abert range of motion. Abert. Now what occurs is you’re having hypo mobility, too little range of motion.
We’re talking at the motor unit, which will be affected at the gross range of motion, but you might have other motor units compensating just like here. Too little, too much. But if you look at the motor unit, that menis. That’s out of place causes hypomobility. But now if you recede that menis with a chiropractic spinal adjustment, because it separates the facets, the menis could go back in.
It can instantly either become normalized, but more likely you’ll see a level of hypermobility if the joint capsule is damaged now in car accident. , I’m telling you empirically, I don’t have this from the literature, that a minimum of 70% of every single car accident causes joint capsule damage. Same thing with any other sport types of sports injuries.
And on. Not for today. So then you’re gonna see hyper mobility because that ligament is overstretched, and that’s called laxity of ligament. And I’m not talking for those who understand personal injury. I’m not talking A O M S I, I am talking pathology of that ligament, primary, secondary, or tertiary, which we don’t see in our office, primary or secondary strain sprain.
So therefore, the only way to diagnose this, Demonstratively. So if you wanna look at getting more treatment for your patient that they need, you need demonstrable validation of those mecan receptors being screwed up in the joint capsule. And the only way to do that is x-ray digitizer to diagnose laxity of the li.
It’s the only way, and you’ll be able to diagnose specifically by name, the facet capsule ligament and Flava Ontario Longitudinal ligament, posterior longitudal ligament, Atlanta Dental Ligament, superspinatus ligament. All of these things you could demonstratively diagnose by name, all of them based upon using x-ray.
Digitizing hyper, hyper. Demonstratively diagnosed is biomechanical pathology folks, and that is the necessity for continued care. If you could show it to be present now, we need to take x-rays, so you need to have demonstrative diagnosis and reporting of those biomechanical lesions. Now, many of you call those biomechanical lesions, vertebral subluxation complex.
I don’t really care what you call them. I really don’t care. And it’s an issue in our industry. Because half the school’s mandate using vertebral subluxation and the other half the schools throw you out. If you even breathe those words, they, they proverbially, persecute you, prosecute you, whatever the word is.
And that’s absurd. We need not run away from our history because it’s quite rich. In coming up with a lot of answers that society needs, but we need not be afraid of evolving into something that’s accepted across the board in every industry. And I can tell you in my formative years being a ultra subluxation only in nothing else in my world, chiropractor and talked only vertebral subluxation complex.
You know how many medical doctors work with me and referred to me and communicated with me? Zero. Zip, not a zilch. , now that I talk biomechanical lesions, hundreds are working with me now and talking to me and asking me for solutions. It also requires x-ray. Now let’s talk about x-ray despite a non-patient centered chiropractic, Political rhetoric.
Diagnostic spinal x-rays had zero zippity doda negative effects. And that’s not my opinion. That’s right from the evidence in the literature in 2009. But if we move on to the evidence in the literature and we look at the American College of Radiology and there are 2020 appropriateness. They say adverse health comes of radiation, doses below a hundred milli serves are not shown by the evidence ra, and this is according to Metler in 2008, radiation exposure to a patient from a plain film is 0.2.
Milli serves hundreds. Normal in cervical, one in thoracic, and 1.5. 1.5. In the lumbar among humans, there is no evidence of a carcinogenic effect for acute radiation of doses, less than a hundred milli serves. You know what that means? It would require an, and by the way, radiation is not cumulative in a single encounter.
5,000 cervical x. 100 lumbar x-rays and 50 lumbar x-rays in a signal encounter. And if you do more than 50 lumbar x-rays or 5,000 cervical in one encounter, your incidence goes up to one in 100,000, which is still minuscule. I’m gonna u radiation is dangerous, you’re gonna have problems. It’s cumulated a had.
It’s all nonsense. It’s not supported by science at any. , and I’m not gonna get into more of this at this point in time, but a certain level of radiation activates the anti-cancer drugs, which is or proteins or things that the human body produces. And I’m not gonna get into that right now, but I just wanna let you know, X-rays in your office are safe.
So what we’re doing. As we’re measuring motor units and we’re digitizing, and this is from a piece of technology called Sim Verta, which is probably one of the most advanced x-ray digitizing platforms in the industry. That’s incredibly simple to use. You, it, you digitize or you just place the corners of the vertebrae plus a piece in the atlas and the ox.
Then what you do in this particular case, you have posterior arch of the atlas and anterior part of the odontoid. You are measuring Atlanta dental interval, which you cannot eyeball. You need to do that on flexion extension. This morning a doctor called me up and said, I did this on a teenager, 15 years old, who was in a sports injury.
He was having terrible headaches. Nobody could find anything. His a d i interval was four point. , you know what I did? Didn’t touch him. Sent him right to a neurosurgeon, didn’t touch him because that is tremendously unstable. And you know what’s behind the Atlanta Dental intervals, the dens. And behind that is your brain step.
Don’t touch. So he knows right away that there’s a transverse Atlanta Dental n Alor ligament that’s unstable and impair. , then we did afl. If we do a flexion extension scenario and we look at inflection, extension, you’ve got three lines. I’m not looking at impairment rating. That’s an administrative award based upon the AMA Guides fourth, fifth, and sixth edition, depending upon your state, the blue line, and we looked at almost all we could find in the literature going back about 30 years.
And what we found is the best representation of pathology. Is 0.78 millimeters of translation. There’s not a lot of leeway there. And there was a plus or minus standard of deviation of plus or minus 22. So we’ve gone to the most conservative side of plus, and we feel that ligaments impair or have pathology at this level right here at yellow.
So we go to the highest under standard of deviation. So this person at C5 has 2.19 millimeters of translation. And at C6 there’s 1.21 millimeters. So I brought this to a neurosurgeon and I said, the non-specific back pain cases you get, which is 99% of the people he goes, He says, we sent ’em to pt.
I said first, if physical therapy versus chiropractic is the first provider, there’s a 313% or evidence of disability versus chiropractic. We get 313% pe better, better e evidence or get ’em off of disability. That PT does, it doesn’t stand the chance. But I said to the surgeon, this is non-specific back.
the problems are coming from c2, mostly from c5, and a little bit from c6. This is extremely specific. And then I went to angular deviation. And by the way, I really screwed this one up. I have lumbar images here and I put a cervical sample here. So as you have smart, I am. But in nonetheless, say this was cervical C six seven, it’s 17.9 millimeters.
And by the way, the surgeon looks at this and says, oh my. I can’t use an artificial disc that changes my prognosis and treatment plan for this patient. I have to change what I do now. Surgeons all over the country are sending their patients to chiropractors who have this type of technology and credentials.
And unique credentials from spinal biomechanical engineering, which is a course that teach doctors.com, which is recognized from the State University of New York at Buffalo Jenkins School of Medicine and Biomedical Sciences Office of continued medical education for post-doctoral medical graduate education.
So right away the surgeons has a peer relationship cuz our doctors have medical school training, and you can do that too. But you say that there’s no fracture, no tumor, no infection, no herniation, and you got this. We know exactly where the problem is. It’s in the superspinatus and infraspinatus ligament.
We know how to fix that. , we know how to work with that patient to stabilize the spine because all the surgeon can do is drug ’em up to shut ’em up, and you can never have a pharmacological solution. To a mechanical problem, simple. The other thing we’ll do in subverted, we’ll give you a roadmap of where and how to adjust and when to adjust anything that goes beyond two standards of deviations.
As you see, this goes to the left, you adjust it to the right, this goes to the right, you adjust it to the left and on, and when you’re treating a patient and when you’re reporting to a carrier, it’s very simple. Here is your individualized, demonstrable, valid. Of biomechanical failure, you’re gonna get paid.
What are they gonna, the only thing that’s left for them to say is we’re not gonna pay just because we don’t want to. That’s the only reason they’re not gonna pay. We don’t want to, that’s all that’s left. So therefore, what you need to do is. Validate it demonstrably. It also prevents lawsuits because the carriers are coming after you for predetermined treatment plans.
Demonstr ability is what you need to do, and you get language in these reports which say, this injury is credit, connective tissue pathology. Of the intra spinus of SuperSPIN is ligament, the say capsule, ligamentum, flava. Here’s your impairment rating. Here’s your diagnoses. These are the things that validate what you do and critically important.
Now, before I finish up, I just want to share with you that I just gave you the basics of probably six hours of. I packed a whole lot of information in a short amount of time. So you really need advanced education on this stuff. You can’t live in the soundbite world. We call out the old chiro one step, two step, 10% for profess to know 200%.
That’s what has kept us down in utilization and has prevented us from having peer relationships. It’s your credentials if you. Lawyers to work with you. Medical primaries, medical specialists, urgent cares, emergency rooms. You need real credentials that are co co credentialed through both medical and chiropractic, academia.
These are the things you need to look at. Range of motion globally. The odds are stacked against you. The second you adjust that patient and you receive that meniscal, you’re gonna go to normal or hyper mobile in a nanosecond, 2, 3, 4 visits, you’re done. Those spasms are gone. That’s why the carriers want you to do that.
The odds are stacked against you. So listen, I’m Mark Studin, it’s been my. Sharing this with you. I look so forward to doing this with you next time. We got so many more things planned. Thank you so much and have a great day.